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THREAD:Professionalism Revealed – Rethinking Quality Improvement in the Wake of a Pandemic
https://bit.ly/2WNDYEV
A culmination of few yrs of thinking, this is something I’ve been meaning to write for some time. Thx to the medical profession for inspiration to put pen to paper
https://bit.ly/2WNDYEV
A culmination of few yrs of thinking, this is something I’ve been meaning to write for some time. Thx to the medical profession for inspiration to put pen to paper
1/As COVID-19 batters our health care system, much has been written about the display of professionalism in medicine. This resource – revealed but not created by the pandemic–may be our best hope for improving care but is under-supported & used (if not undermined) in normal times
2/When we return to the daunting task of improving health care delivery, we should ask how the professionalism of clinicians can be more productively tapped. In this piece, I re-approach quality improvement focusing on the linchpin of delivery – provider agency
3/Here are snippets from the start and end. Lots more in the middle. Many thanks to @nejmcatalyst for giving it a home with some elbow room (authors: highly recommend). In next tweets, I’ll summarize
4/1st I consider the inherent limitations of current strategies that rely on quality measures. While measurement has been an advancement, these strategies will not get us to where we want to be. It’s time to try other ideas
5/2nd I take a step back and re-approach w/ some basic economics, state of evidence, & observations. This reminds us of reason we are trying strategies like P4P (to correct market failures) and helps refocus on agency (informed & motivated physicians acting on patient’s behalf)
6/Physicians are not perfect agents. But the recent professional response is arguably indisputable evidence that professionalism is undertapped. We get a lot of value-based care w/out value-based payment, so if health care professionals have more to offer, we need to harness that
7/3rd I offer several possible directions for quality improvement conceived as targeting problems of information or intrinsic motivation when providers act as agents. In short, how can we support and leverage professionalism more productively?
8/These strategies need not rely on measures. Physicians’ collective ability to observe and learn can be better tapped and their intrinsic motivation fanned. And they are not confined to practice management (e.g., informed motivated clinicians can drive QI via the labor market)
9/This article intends to advance the conversation on quality. To that end & bc it’s hard to keep up w/ Twitter these days (knackered says @JohnMullahy) I’ll tag a bunch of people who think/write RE quality/incentives/behavior. I’m sure I’m leaving many off so plse loop others in
10/Finally, I want to emphasize 3 points to pre-empt dismissiveness of this line of thinking: Point 1: physicians do not need to be perfect agents for these strategies to foster improvement. There will always be bad behavior...
11/Often, however, it’s the business not the professionals responsible, as @zackcooperYale noted recently about surprise billing. I devote a section to the importance of aligning organizational goals w/ those of the profession
12/Point 2: I am not suggesting a return to greater self-regulation of practice by the profession and explicitly state this:
13/Point 3: some may argue that medical professionals rising to the occasion is no different than other essential workers doing same. But what’s different in medicine is that in many ways the pandemic isn’t new – intense & compressed, yes, but patients suffer in normal times too
14/Medicine is distinct in its high concentration of human capital & humanity. When we squander professionalism, the consequences are perennially severe. The recent response by clinicians should make us think twice if we are assuming that we’ve made the most of this resource
15/Special thanks to Tom McGuire for engaging w/ me on these ideas. And thx to @LeemoreDafny, @MWFriedberg, @timothyjlayton, @AdamLBeckman, and 3 anonymous referees for helpful comments on an earlier draft. Now will tag some folks
Food for thinkers/writers/leaders: @donberwick @HelenBurstin @DavidBlumenthal @Atul_Gawande @vivek_murthy @sacjai @LisaRosenbaum17 @jtkolstad @Asaf_Bitton @Farzad_MD @kevin_volpp @ZekeEmanuel @bobkocher @Cutler_econ @LarryCasalino @rm_werner @medicarepayment @SecMandyCohen
@sacjai @amitabhchandra2 @DrSimpsonHSR @Institute4AC @Fdebrantes @ThomasHLeeMD @MelindaBBuntin @jzayanian @robert_huckman @j_r_a_m @afrakt @miteshspatel @jdimick1 @JohnBirkmeyer @JonSkinner17 @Michael_Chernew @Mblandrum @jasndoc @oziadias @johngraves9 @valeriealewis @chimandum
@eric_t_roberts @EricSchneiderMD @PatrickConwayMD @SuzanneDelbanco @dmgorenstein @AnupamBJena @kejoynt @ashishkjha @ASlavitt @NatQualityForum @TimGDC @rkwadhera @themoruknow @healthecon_dan @danielleofri @RFRedberg @howardbauchner @robertwdubois @rwyeh @ml_barnett @Ateevm
@AmolNavathe @atheendar @CHColla @aaronecarroll @sangerkatz @jrovner @sarahkliff @Andy_Ryan_dydx @jwswallace @MarkMiller_DC @ReedAbelson @_melaevans @annawmathews @MartinSGaynor @Meyer_HM @Bob_Wachter @bobjherman @jeffreylinder @jflier @MJPany @chenlucy8 @micahbaaron
@DavidCGrabowski @Bruce_Landon @HealthEconTX @peterubel @asacarny @JeffKullgren @gelb_dana @BradleyFlansbau @WillShrank @DhruvKhullar @DrKatzNYCHH @davechokshi @glensteele OK I am missing tons but this list is starting to get out of hand. FIN
